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Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: a Biomechanical Analysis and Implications for Management

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Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: a Biomechanical Analysis and Implications for Management ORIGINAL ARTICLE Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: A Biomechanical Analysis and Implications for Management Melody Lee, MD; Elizabeth A. Huntoon, MD, MS; and Mehrsheed Sinaki, MD, MS Abstract Objective: To analyze injuries that were directly associated with yoga practice and identify specific poses that should be avoided in patients with osteopenia or osteoporosis. Patients and Methods: We retrospectively reviewed the medical records of patients with injuries that were primarily caused by yoga. Patients were seen from January 1, 2006, through December 31, 2018. Injuries were categorized into 3 groups: (1) soft tissue injury, (2) axial nonbony injury, and (3) bony injury. Patients underwent evaluation and were counseled to modify exercise activity. Results: We identified 89 patients for inclusion in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease (46 patients [51.7%]) and facet arthropathy (n¼34 [38.2%]) were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%). Spondylolisthesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. We correlated the kinesiologic effect of such exercises on specific musculoskeletal structures. Conclusion: Yoga potentially has many benefits, but care must be taken when performing positions with extreme spinal flexion and extension. Patients with osteopenia or osteoporosis may have higher risk of compression fractures or deformities and would benefit from avoiding extreme spinal flexion. Physicians should consider this risk when discussing yoga as exercise. ª 2018 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2019;94(3):424-431 oga is an ancient practice believed to turning to their primary care physicians for have originated over 5000 years ago, guidance regarding yoga safety, it is important For editorial Y with the first mention of it in the Rig for physicians to be aware of the risks and ben- comment, see Veda, one of the oldest sacred Indian texts. efits of yoga. page 385; for The practice flourished and gave rise to many The benefits of yoga in terms of flexi- related article, see distinct variations, eventually being brought bility, strength, and balance are widely page 432 to the Western world in 1893 when the young known. Many health care professionals From the Department of yogi Swami Vivekananda introduced yoga at have encouraged the practice of yoga, tout- Physical Medicine and Reha- the World’s Parliament of Religions in Chi- ing it as a safe exercise for patients at bilitation, Mayo Clinic, 1 1,4,5 Rochester, MN (M.L., M.S.); cago. Since then, yoga has gained immense different levels of health. However, mul- and Department of Physical popularity as a form of exercise and relaxation. tiple reports have described injuries result- Medicine and Rehabilitation, Nationally representative studies in the United ing from yoga, ranging from mild muscle Virginia Commonwealth Uni- 6,7 versity, Richmond, VA States have reported that the 12-month preva- strains to bony fractures. For osteoporotic (E.A.H.). lence of yoga practice has increased from 3.8% and osteopenic patients in particular, the re- in 2004 to 8.9% in 2016, with a lifetime preva- ports of bony injuries raise concerns that lence of 13.2%.2,3 With patients increasingly warrant further investigation. 424 Mayo Clin Proc. n March 2019;94(3):424-431 n https://doi.org/10.1016/j.mayocp.2018.09.024 www.mayoclinicproceedings.org n ª 2018 Mayo Foundation for Medical Education and Research SOFT TISSUE AND BONY INJURIES ATTRIBUTED TO YOGA With some exceptions, the literature to rest were from across North America. Base- date does not appear to recommend suffi- line patient characteristics are shown in cient caution or accommodations for yoga Table 1. The patients had various age-related in patients with impaired bone integrity.4 comorbid conditions, such as hyperlipid- Some authors even suggest yoga as an excel- emia, hypertension, and osteoporosis. Our lent exercise for patients with osteopo- rosis.5,8 Little to no guidance is available regarding maneuvers that are potentially TABLE 1. Baseline Characteristics of the 89 Study dangerous. Our primary aim in this study Patientsa was to identify patients who were injured Characteristic Value while practicing yoga and to determine the Age (y) specific poses that caused their injuries. We Mean Æ SD 58.3Æ13.6 defined injury as musculoskeletal pain or Range 21-87 discomfort severe enough for a patient to Female sex 80 (89.9) seek physician evaluation. Our secondary Height (cm) aim was to identify poses that should be Mean Æ SD 165.6Æ8.6 avoided based on these results and kinesio- Range 145.5-188 logic principles, particularly for patients Weight (kg) with underlying osteopenia or osteoporosis. Mean Æ SD 74.3Æ14.3 Our goal is to provide guidance to physicians Range 50.5-89.0 b who care for patients who practice yoga. Pain score Mean Æ SD 6.2Æ2.6 Yoga has many benefits, but it is by no Range 0-10 means a completely benign form of exercise, T score (n¼43) and caution is warranted when counseling Mean Æ SD À2.05Æ1.24 patients on its practice. Range 1.1 to À4.7 Working status PATIENTS AND METHODS Retired 30 (33.7) This study was approved by the Mayo Clinic Working full-time 37 (41.6) Institutional Review Board. We retrospec- Working part-time 3 (3.3) tively reviewed the medical records of pa- On disability 1 (1.1) Homemaker 12 (13.4) tients with injuries that were primarily Student 2 (2.2) caused by yoga. The study cohort consisted Unemployed 4 (4.4) of patients who had been referred to the Comorbid conditionsc musculoskeletal clinic by their primary care Cancer 24 (27.0) physicians for evaluation of the etiology of Osteoporosis 22 (24.7) their pain. All patients had been referred to Hyperlipidemia 23 (25.8) the senior author (M.S.), who has special in- Osteopenia 19 (21.3) terest in osteoporosis and musculoskeletal Headache 11 (12.4) Hypertension 13 (14.6) health. Patients were seen from January 1, Hypothyroidism 14 (15.7) 2006, through December 31, 2018. Clinical Depression 12 (13.5) characteristics of patients in the cohort Vitamin D deficiency 10 (11.2) were obtained retrospectively from their Anxiety 8 (9.0) health records. Marital status Married 72 (80.9) RESULTS Divorced 8 (9.0) Single 7 (7.9) Patient Characteristics and Evaluation Widowed 2 (2.2) We identified 89 patients for inclusion in aData are presented as No. (percentage) of patients unless this series. Of these, 37 (41.6%) resided indicated otherwise. bPotential pain scores ranged from 0-10. within the same state as our clinic, 1 was c Some patients had more than one comorbid condition. from Panama, 1 was from India, and the Mayo Clin Proc. n March 2019;94(3):424-431 n https://doi.org/10.1016/j.mayocp.2018.09.024 425 www.mayoclinicproceedings.org MAYO CLINIC PROCEEDINGS body height and were determined to be de TABLE 2. Location of Pain at Initial Evaluation novo based on magnetic resonance imaging ¼ a Location No. (%) (N 89) and comparisons of prior radiographs, Cervical spine 23 (25.8) computed tomographic images, or positron Thoracic spine 30 (33.7) emission tomographic scans. Within the Lumbar spine 53 (59.6) soft tissue group, 66 patients (74.2%) had Sacral spine 22 (24.7) mechanical myofascial pain due to overuse. Shoulders 19 (21.3) Rotator cuff injury was seen in 6 (6.7%), Hips 10 (11.2) and trochanteric bursopathy was observed Thighs 4 (4.5) in 1 (1.1%). In the axial group, exacerbation Knees 5 (5.6) of pain in degenerative joint disease (46 pa- ¼ Feet or ankles 3 (3.4) tients [51.7%]) and facet arthropathy (n 34 Elbows 1 (1.1) [38.2%]) were observed. Radiculopathy was Wrists 1 (1.1) seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on aSome patients had pain at more than one location. imaging in 15 patients (16.9%). Spondylolis- thesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), patient population had a higher rate of oste- and compression fractures were present in oporosis than the general American popu- 13 (14.6%). Of note, 12 of the patients lace, with 24.7% (22 of the 89 patients) with vertebral compression fractures were having documented osteoporosis as opposed included in previous reports.7,10 In this to the estimated 10.3% prevalence in the 9 study, we further analyzed their exercise United States. The youngest patient had programs and identified the poses that Ehlers-Danlos syndrome. The patients were were blamed for their injuries. We also iden- otherwise generally healthy and enjoyed be- tified yoga-related anterior wedging in 16 pa- ing active, participating in other nonstrenu- tients, which has never been described ous exercises such as tai chi or pilates. before. All bony injuries appeared to be Many patients reported pain in the back, related to yoga exercises involving spinal neck, shoulder, hip, and knee (Table 2), and flexion, as described by the patient. many had multiple areas of discomfort. Appropriate imaging and evaluation were pursued.
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